Diabetes mellitus

Background

• Disorder of glucose metabolism resulting in chronically elevated serum glucose levels

Causes and Classification

• Type 1: absolute insulin deficiency from beta-islet cell destruction
  • Type 1a: autoimmune beta-islet destruction
  • Type 1b: beta-islet destruction without known cause
  • Latent autoimmune diabetes in adults (LADA) (type 1.5): insulin resistance that progresses to autoimmune diabetes and insulin dependency over several years
• Type 2: insulin resistance and varying degrees of insulin deficiency
• Genetic conditions
  • Maturity-onsent diabetes of the young (MODY): autosomal dominant condition that causes type 2 diabetes in those under 25
  • Wolfram syndrome: diabetes insipidus, diabetes mellitus, optic atrophy, and deafness (DIDMOAD)
• Exocrine pancreas disorders
  • Cystic fibrosis
  • Hereditary hemochromatosis
  • Chronic pancreatitis
  • Fibrocalculous pancreatic diabetes
• Drug-induced
  • Steroids
  • Many others
• Stiff-person syndrome
• Anti-insulin receptor antibodies

Management

ABCDESSS

• A1c targets: ≤7% (or ≤6.5 to decrease disk of CKD and retinopathy)
• BP targets: <130/80 mmHg
• Cholesterol targets: LDL <2 mmol/L or >50% reduction from baseline
• Drugs for CVD risk reduction
  • ACEi/ARB if CVD, age ≥55 with risk factors, or diabetes complications
  • Statin if CVD, age ≥40 (for type 2), or diabetes complications
  • ASA if CVD
  • SGLT2i/GLP1ra if type 2 with CVD and A1c not at target
• Exercise goals and healthy eating
  • 150 minutes of moderate-to-vigorous aerobic activity weekly, with resistance exercise 2-3 times weekly
  • Health dietary pattern such as Mediterranean diet or low glycemic index diet
• Screening for complications
  • Cardiac: ECG every 3-5 years if age >40 or diabetes complications
  • Foot: monofilament or vibration testing yearly, or more often if abnormal
  • Kidney: creatinine and ACR yearly, or more often if abnormal
  • Retinopathy: yearly for type 1, every 1-2 years for type 2
• Smoking cessation: ask permission to give advice, refer for therapy, and provide support
• Self-management, stress, and other barriers
  • Set personalized goals
  • Assess for stress, mental health, and financial concerns that might be barriers to achieving goals